• Authorizations

  • Prior Authorization For Medical Services (Non-Pharmacy Services)

    A prior authorization request is a request made by the member or a provider on the member’s behalf for approval of a medical service based on medical necessity and eligibility for coverage before said covered service is provided to the member. In order to determine the medical necessity of a service and reduce the time from when a request is made to when it is approved, the authorization request should be accompanied by all necessary clinical information that supports the request for service. Once clinical information is received and reviewed, and an approval is granted, an authorization number will be assigned to the request for billing purposes. In order for the claim to be eligible for reimbursement, the service authorized must match the service on the claim and the claim’s received date must be after the authorization approval date.

    Affinity’s preferred method for receiving prior authorization requests is via fax, using fax number 718.794.7822. Please use our Prior Authorization Form and include all relevant clinical information supporting your request for timely determination. Failure to do so may result in a delay in authorization or return of request.

    If you prefer to speak with a representative in person please call 888.543.9074. To check on an authorization status in real time, log into the provider portal.

    Effective January 1, 2019, Medicare membership transitioned to EmblemHealth. Affinity will continue to provide customer service and pay claims for services rendered in 2018. However, for any services related to pre-authorizations, providers MUST contact EmblemHealth:
    via fax at 866.215.2928
    via their provider portal at https://www.emblemhealth.com/Providers

    You may check the status of pending Medicaid, Child Health Plus, HARP, and Essential Plan authorizations by logging on to the Affinity Provider Portal. If you do not have access to the Portal, please register through the Portal icon on the top of the page. All you need is the authorization reference number provided by Affinity when the request for service was first made. In addition to accessing real-time authorization statuses online via the Affinity Provider Portal, you may search if a service requires a prior authorization. Our goal is to provide a faster turnaround for each authorization and reduce the time you spend on the phone.

    You may still use our automated phone line at 888.543.9074 to review an authorization status. You will need the authorization reference number provided by Affinity when the request for service was first made.

    Note: Failure to comply with the requirements described above may result in claims being denied in whole or in part and, as required under your agreement with us, the member being held harmless.

    Retrospective Review

    A retrospective review is the process of determining coverage post service. Affinity’s retrospective review is limited to:

    • Unable to Know Situations
      • The member is not able to inform the provider about their insurance coverage, or the provider verified different insurance coverage prior to rendering services.
      • The member is unable to speak (e.g., intubated or in a coma) and cannot provide insurance information.
    • Unable to Verify Primary vs. Secondary Insurance Coverage *
      In this case, we will honor authorizations from the primary carrier as long as the service is a covered benefit.
    • Not Enough Time Situations *
      The member requires emergency medical services and pre-authorization cannot be completed prior to service delivery. In this case, Affinity will accept the authorization request as long as it is received as soon after the emergency has been handled, and the request is made prior to submitting the claim for payment.

    * In these cases, please notify us within 24 hours after insurance is verified and include clinical and supportive documentation describing the reason for the delay in the authorization request.

    Along with the request for a retrospective review, all clinical documentation to support the review must be received with the request from the provider.

    Affinity’s Provider Portal and automated line for providers offer information on the status of an authorization request. When logging on or when calling 888.543.9074, a provider must have the authorization number ready in order to verify if an authorization is approved or denied. These services allow for an expedited process and eliminate the need to call the Affinity Medical Management for authorization status.

    Affinity Health Plan is continuing our expanded partnership with eviCore Healthcare.

    eviCore manages the authorization process for radiation therapy, ultrasound, sleep management, physical therapy (PT), occupational therapy (OT), speech therapy (ST), cardiac imaging and radiology services. For more information and codes related to these services, please visit evicore.com/healthplan/Affinity or call 866.242.5615 and choose option number 6.

    The following is clarification on the authorization services provided via Affinity Health Plan’s recently expanded partnership with eviCore Healthcare:

    • Ultrasound
      For a routine pregnancy, the first two ultrasounds – nuchal translucency (76813) and fetal anatomy survey (76805) – do not require prior authorization. Any additional ultrasounds will require prior authorization.
    • Non-Obstetric Ultrasounds
      The first ultrasound for any one specific condition (e.g., pelvic ultrasound for pelvic pain, thyroid ultrasound for a thyroid mass, renal ultrasound for hematuria) does not require a prior authorization. Any additional ultrasound for the same condition will require prior authorization.
    • PT/OT/ST
      Prior authorization is not required for the first six visits within the benefit period. Visit seven and beyond will require prior authorization. Please refer to the specific program benefits for limitations.
    • Sleep Study Supplies
      Prior authorization is required every three months. Out-of-network services or services rendered by a non-participating physician or provider continue to require prior authorization. Participating Affinity providers must refer to in-network providers and/or render services in in-network facilities.

    All admissions through emergency departments require notification within 24 hours of the admission in order to obtain authorization for continued inpatient stay.

    See all authorization forms.

    Appeals and Grievances

    As an additional reminder, all appeals should contain a cover letter or memo clearly stating the reason for the appeal and the rationale for why Affinity should reconsider its position. Documentation (if necessary) should be included to support the rationale stated in the letter. If a claim was submitted and denied, a copy of the claim and/or explanation of payment should be included with the submitted material. If numerous pages are attached to the letter, please ensure you have tabbed or referenced the key information supporting your appeal. Affinity will make its decision based upon solid information that is concisely supported. If when the appeal is filed the information needed for reconsideration is not readily available, Affinity will, in all likelihood, uphold its original determination.

    Appeal support should follow the original reason for denial. If a claim was originally denied because of lack of authorization, the provider should include rationale for why no authorization was requested with any appeal submitted, instead of including medical necessity information. Administrative denials cannot be ‘turned into’ medical necessity appeals.

    Effective January 1, 2019, Medicare membership transitioned to EmblemHealth. For any services related to appeals for care rendered in 2019, providers MUST contact EmblemHealth at:
    Medicare HMO
    P.O. Box 2807
    New York, NY 10116-2844
    Fax: 212.510.5320

    High Dollar Claim

    Affinity may request medical records or itemized bills for certain high dollar claims with amounts paid outside of the DRG base rate. If additional materials are needed for review, Affinity will deny the claim for an itemized bill and/or medical record. Additional materials should be included with a corrected claim and sent to Affinity as a resubmission. This will ensure all materials are correctly sent to the proper person for prompt review and payment.